Recently, I had a friend who had a request for a substantial sum of money to be refunded for infrared heat, 97026, as he billed and was paid for multiple units. My friend was confused on billing units for physical medicine services and asked "can I bill services such as heat, electrical stimulation, massage etc. for multiple units?"
Modalities are the first codes listed in this section of Current Procedural Terminology, CPT, and they are defined as a physical agent applied to produce therapeutic changes to biologic tissue. However, there are two distinctions to these modalities and they are designated as "supervised" and "constant attendance."
Supervised modalities do not require direct or constant one-on-one contact by the provider during the time the therapy is applied. These include thermal modalities such as 97010 hot packs, diathermy 97024, infrared 97026, whirlpool 97022 and paraffin bath 97018. Included is electrical stimulation (unattended) 97014, where pads are affixed to the surface of the skin to deliver electrical impulses. All services, which are coded from 97010 through 97028, may only be billed as one unit per visit, regardless of the number of regions the service is applied or the time of application.
Therefore, the example of 97026 being requested for a refund is likely correct in that this service cannot be billed in multiple units. If it was billed in multiple units and paid there would be an overpayment for any amounts over one unit per visit and that would have to be refunded.
A good general rule is that any physical medicine service that does not require constant attendance (meaning you can place the service on the patient and leave them unattended) should be billed only for one unit maximum.
Special note acupuncture (97810, 97811, 97813, and 97814 needling) is not a physical medicine service and do not follow this protocol of supervised modalities and are billed according to the sets of needles applied and not related to the time of needle retention.
The second type of modalities are "constant attendance" these also are physical agents applied to achieve a biologic response but require direct contact by the provider during the entire time of the service. Due to the need of constant attendance these services may be billed in units based on time of application. The number of regions of service do not alter the units, but the entire time of the application.
These services are coded from 97032 to 97036 and include attended electrical stimulation 97032, which unlike the unattended electrical stimulation is delivered by a hand held device that produces the electrical stimulus to the surface of the skin. This is often used to work a broader surface area or specific areas on an intermittent basis. Ultrasound 97035 and contrast baths 97034 are also in this category. These services may be billed in multiple units based on total time of application.
Units under CPT are designated as 15 minutes, though per Centers for Medicare and Medicaid services CMS, and adopted by all major insurers it is not a requirement that 15 minutes necessarily be spent to qualify for one unit.
- 1 unit = 8-22 minutes
- 2 units = 23-37 minutes
- 3 units = 38-52 minutes
- 4 units = 53-67 minutes
When documenting in the chart it is paramount to indicate the specific time of application as time is what you are being reimbursed for. A very important aspect to this is multiple timed procedures which are billed in units, but based on cumulative time for all timed services. Therefore, if two timed services were done in a single visit and each was done for 10 minutes they would not qualify to have both billed, as the total time of services were only 20 minutes which qualifies as one unit.
The highest valued service would be billed with one unit and the other is not billable. It is paramount document actual time as one unit is equal to as little as eight minutes and as much as 22. In the example above it is possible if time was carefully documented and 12 minutes was noted on each service for a total of 24 minutes then both services could be billed for one unit as 24 minutes qualifies for two units of total billing.
Of special note, for these timed services, they include in their overall time some preservice and post-service time for preparation and clean-up. However, the majority of time must be for the actual service.
Therapeutic procedures 97110 through 97535 (this excludes 97150) are also timed services and may be billed in units also. This includes therapeutic exercise 97110, massage 97124, and manual therapy 97140 which are commonly used by acupuncture professionals as an adjunct to acupuncture.
Time is an important factor for billing physical medicine services and as a simple rule if the service can be done unattended, meaning you can place the service and leave the patient for a time, it cannot be billed in units. Conversely services that require your attendance the entire time of application may be billed in units.
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